Among the problems with the state's new mandatory health insurance program that are rearing their ugly heads: resistance from providers. Complaints are flying that new enrollees looking for doctors they can access under the state-offered plans are unable to find them.
"As of last week, there are no more providers on Cape Cod accepting new Commonwealth Care patients," was the complaint posted by a worried reader on a Cape Cod Times blog late this summer. "They are forcing us to buy an insurance plan that is worthless, because we can't find a primary care doctor that will take new patients."
What does the situation look like from the provider's point of view? Consider the case of Dr. Andrew Schamess of Lenox Internal Medicine, who wanted to be a participating provider under the new program.
Schamess, a UMass Medical School gradwho set up his solo practice last year after 10 years working for other health care organizations, soon learned that participation under the terms stated by the program could put him in the red.
The problem: if he accepted patients covered under Commonwealth Care, the insurance program for low-income patients, he couldn't limit the number he took (unless it reached 1,500, the maximum the program allows). Under the rules governing the program, he couldn't turn away new Commonwealth Care patients unless he closed his practice to privately insured patients.
"When I looked at the contract, the reimbursement was low—that is, lower than that for my privately insured patients," Schamess told the Advocate. "My entire load is 2,500 patients, so for me to take 1,500 Commonwealth Care patients would be insane.
"I would not expect the state to pay the rates Blue Cross/Blue Shield pays. But when I went back to them and said, I've got to try to take some patients and see how it works out, they were absolutely adamant that it had to be all or nothing." At that time, according to Schamess, some of his colleagues in Berkshire communities thought it was too risky to participate in the program.
But Schamess kept on talking with the HMO he wanted to sign up with: Boston Medical Center Health Net, one of several HMOs that are administering the mandatory insurance program under contract to the state. "I think they're a pretty decent health company," Schamess said.
What ensued was all too well known to physicians who deal with HMOs on a regular basis: a headbutting session about whether the insurer or the doctor was going to eat the risk for low-income patients whose health status was in many cases unknown because they had previously been uninsured. Moreover, low-income patients typically have more health problems than wealthier ones, and fewer resources to help deal with them—less access to good housing and nutrition and preventive health care, for example. As Schamess explained, "I'll see patients for free, for $25, for cordwood. But it's different when you're signing a contract to take 1,500 patients. They may turn out to be very high consumers."
Eventually negotiations ended well. "When I finally reached the right person," Schamess said, "we reached an accommodation. …I am taking some of these people. I've always been a public health guy and I'm very committed to this." But, he said, the state's contract writers "need to think about their rates and the terms of their contracts if they want primary care doctors to pick these people up."
The problem of provider flight is one the state already knows too well. The trouble Medicaid recipients in Massachusetts have had finding dentists who would take them is legendary. If the new health care "reform" program simply replays the troubled history of Medicaid on a wider screen, the captive purchasers of compulsory insurance will be worse off than they were before the health care reform experiment began.
